Metabolic health phenotypes and cardiovascular disease among U.S. adults with central obesity: Evidence from NHANES 2011– March 2020

Background: Central obesity is strongly associated with cardiometabolic dysfunction and cardiovascular disease (CVD), yet CVD burden may vary by metabolic phenotype among affected adults. This study examined whether metabolically unhealthy central obesity (MUCO) is associated with higher CVD prevalence than metabolically healthy central obesity (MHCO), whether CVD increases in a dose-response manner with metabolic abnormality burden, and whether associations vary by age, sex, and race/ethnicity. Methods: We conducted a cross-sectional analysis of NHANES 2011-March 2020, including adults ≥20 years with central obesity (≥102 cm (40″) in men; ≥88 cm (35″) in women). Metabolic phenotype was defined by four abnormalities: elevated blood pressure (≥130/85 mmHg or antihypertensive use), dysglycemia (HbA1c ≥ 5.7%, self-reported diabetes, or diabetes medication use), low HDL cholesterol (<40 mg/dL in men or <50 mg/dL in women), and hypercholesterolemia (physician diagnosis or lipid-lowering therapy). Participants were classified as MHCO (0-1 abnormality) or MUCO (≥2 abnormalities); abnormalities were summed (0-4) to assess dose-response. The outcome was self-reported physician-diagnosed CVD (coronary heart disease, myocardial infarction, stroke, heart failure, or angina). Survey-weighted Poisson regression estimated adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs). Results: Among 11,657 adults with central obesity, 6,997 were MHCO and 4,660 MUCO, representing 128.4 million U.S. adults. Weighted CVD prevalence was higher in MUCO than MHCO (15.7% vs 7.3%). After adjustment, MUCO was associated with higher CVD prevalence (PR 1.48; 95% CI 1.30-1.68; p < 0.001). Each additional metabolic abnormality increased CVD prevalence by 29% (PR 1.29; 95% CI 1.21-1.38; p < 0.001). The association was strongest among adults aged 20-39 years (PR 3.89; 95% CI 2.22-6.81), despite low absolute prevalence. Conclusions: Among U.S. adults with central obesity, metabolic dysfunction is associated with higher CVD prevalence, with a clear dose-response relationship. These findings support phenotype-based cardiovascular risk stratification beyond waist circumference and emphasize early identification and management of metabolic abnormalities, particularly in younger adults.